Original Article

Stress, Depression, Sexual Function, and Alexithymia in Infertile

Females with and without Polycystic Ovary Syndrome:
A Case-Control Study
Zahra Basirat, M.D.1, Mahbobeh Faramarzi, Ph.D.1*, Seddigheh Esmaelzadeh, M.D.1, Sharareh Abedi Firoozjai, M.Sc.1,
Theresa Mahouti, B.Sc.1, Zahra Geraili, M.Sc.2

1. Infertility and Health Reproductive Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
2. Social Determinants of Health Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran

Abstract
Background: Infertile females experience some types of distress such as social stress, depression, and sexual dys-
function that may be exacerbated by polycystic ovary syndrome (PCOS). The current study aimed at comparing
psychological profile of infertile females with PCOS with that of women without PCOS with respect to four domains:
infertility stress, depression, sexual dysfunction, and alexithymia.
Materials and Methods: The current case-control study was conducted on 240 infertile females (120 with
PCOS and 120 without PCOS) in Fatemeh Azahra Infertility and Reproductive Health Research Center (Babol,
Iran) from 2016 to 2017. The following questionnaires were used to collect data: the fertility problem inven-
tory (FPI), the female sexual function index (FSFI), the Beck depression inventory-II (BDI-II), and the Toronto
alexithymia scale (TAS-20).
Results: Females with PCOS had higher FPI total scores than the ones without PCOS (120.68 ± 29.42 vs. 112.83 ±
30.94). Of the subscales of infertility stress, the mean scores of social stress and rejection of a future life without a
child were higher in females with PCOS than the ones without PCOS (P<0.05). Also, the mean total scores of alexithy-
mia symptoms (TAS-20) in females with PCOS were significantly higher than those of the ones without PCOS (59.83
± 11.36 vs. 55.69 ± 11.52). There was no significant difference between the two groups regarding the mean scores of
depression symptoms and sexual function.
Conclusion: Infertile females with PCOS experienced higher levels of infertility stress and inability to distinguish
and describe their feelings compared with the ones without PCOS. It is suggested that infertility care providers should
provide more psychosocial support for infertile females with PCOS.

Keywords: Alexithymia, Depression, Infertilty, Polycystic Ovary Syndrome, Sexual Dysfunction

Citation: Basirat Z, Faramarzi M, Esmaelzadeh S, Abedi Firoozjai Sh, Mahouti T, Geraili Z. Stress, depression, sexual function, and alexithymia in infertile females
with and without polycystic ovary syndrome: a case-control study. Int J Fertil Steril. 2019; 13(3): 203-208. doi: 10.22074/ijfs.2019.5703.

Introduction cluding menstrual irregularity, hirsutism, and acne may

Polycystic ovarian syndrome (PCOS) is one of the
most common etiological factors of infertility which is
identified in up to 20% of infertile females (1). Stud-
ies emphasized that the prevalence of psychiatric dis-
orders is high in patients with PCOS. A longitudinal
study reported a prevalence of 40% for depression in
patients with PCOS (2). A cohort study reported that
PCOS can increase the risk of schizophrenia, bipolar
disorder, personality disorders, and tics (3). Other psy-
chiatric disorders such as anxiety, eating disorders, and
sexual dysfunction disorders are common in patients
with PCOS (4). In addition, females with PCOS report-
ed lower body image satisfaction compared to the ones
without PCOS (5). Clinical manifestations of PCOS in-
exacerbate distress in the affected females (6).
Many females experience infertility as a feeling of
distress and stigma (7). Infertile females experience
some types of distress such as social stress, depression,
sexual dysfunction, and marital dissatisfaction (8-10)
that may be exacerbated by PCOS. Kitzinger and Will-
mott (11) introduced PCOS as a stigma, “the thief of
womanhood”. Infertile females with PCOS and infertil-
ity problems may experience being less feminine, due
to excessive hair growth and absence of or irregular
menstrual periods (12). Additionally, infertility man-
agement processes such as assisted reproductive tech-
niques are more stressful in females with PCOS than
the ones without it (13).

Received: 20/August/2018, Accepted: 7/January/2019

*Corresponding Address: P.O.Box: 4719173716, Infertility and Health Re-
productive Research Center, Health Research Institute, Babol University of
Medical Sciences, Babol, Iran
Email: mahbob330@yahoo.com
Royan Institute
International Journal of Fertility and Sterility
Vol 13, No 3, October-December 2019, Pages: 203-208

203

Alexithymia is a personality construct with inability
in normal affect regulation that is comprised of five
characteristics including difficulty to identify and dis-
tinguish emotions from bodily sensations, difficulty to
describe and verbalize emotions, externally oriented
thinking style, poverty of fantasy life, and poor empa-
thy (14). This personality construct is a risk factor for
various physical and mental health problems including
anxiety, depression, compulsive or addictive behav-
iors, physical symptoms, and potentially somatic dis-
eases (15). Since a previous study showed that infertile
females had higher rates of alexithymia than the fertile
ones (16), it was assumed that the rate of alexithymia
may differ among infertile females with different levels
of stress. Therefore, infertile females with PCOS may
have different levels of alexithymia compared with the
ones without PCOS.
Although many previous studies indicated that psy-
chiatric disorders are common in patients with PCOS
(2-6), few researches reported psychiatric symptoms
in females with PCOS and infertility. Diamond et al.
(16) concluded that female sexual dysfunction does not
vary between infertile females with PCOS and the ones
with unexplained infertility. Another study reported that
infertility did not appear to constitute a risk factor of
psychological distress in females with PCOS (17). As
differences in psychological profiles between infertile
females with PCOS and those without PCOS are not
clear yet, the current study aimed at comparing the psy-
chological profile of these two groups. To the authors’
best knowledge, it was the first study that compared psy-
chological profiles of infertile females with and with-
out PCOS in terms of four domains: infertility stress,
depression, female sexual dysfunction, and alexithymia
(i.e. the inability to distinguish and describe feelings and
the absence of fantasies).
Materials and Methods
Participants
The current case-control study was conducted in Fate-
meh Azahra Infertility and Reproductive Health Re-
search Center (Babol, Iran) from May 2016 to December
2017 on 240 infertile females selected through census
sampling method. The case group was composed of 120
females with a definite diagnosis of PCOS. The control
group was comprised of 120 infertile females without
PCOS based on Rotterdam diagnostic criteria. Besides,
the control group was matched with the case group in
terms of age, level of education, and duration of infertil-
ity.
Inclusion criteria for infertile females with and with-
out PCOS were being 15-45 years old, completion of
primary school as the minimum level of education, be-
ing married and having an active sex life, and lacking
any problems in speaking or understanding the Persian
language; also, a definite diagnosis of PCOS was an
additional criterion for PCOS group. Definite diagnosis
Psychological Profile of Infertile Women with PCOS
of PCOS was done based on two of the following Rot-
terdam diagnostic criteria: ultrasound scan of PCOS
(presence of ≤12 follicles in one or both ovaries and/
or increased ovarian volume >10 mL), clinical signs of
hyperandrogenism (hirsutism or obvious acne), and/or
an elevated plasma testosterone level, and/or irregular
menstrual periods (interval between menstrual periods
>35 days, amenorrhea defined as the absence of vaginal
bleeding for ≥6 months, and/or variable menstruation)
(18, 19).
Exclusion criteria for all participants (females with
and without PCOS) were diagnosis of the husband with
azoospermia or oligospermia, presence of other disor-
ders that could mimic PCOS syndrome such as congeni-
tal adrenal hyperplasia, thyroid disease, or hyperprol-
actinemia.
Procedure
Four staff of the infertility center explained the study’s
objectives to the participants and accordingly, the sub-
jects were required to sign the written informed consent
forms. The staff interviewed the subjects and recorded
their demographic characteristics, as well as their medi-
cal and gynecological history. Furthermore, the subjects
were asked to complete five questionnaires of the study
including the fertility problem inventory (FPI), the fe-
male sexual function index (FSFI), the Beck depression
inventory-II (BDI-II), and the Toronto alexithymia scale
(TAS-20). First, 258 females (129 with and 129 without
PCOS) were enrolled of which 240 females with infer-
tility (120 with and 120 without PCOS) completed the
questionnaires.
Ethical considerations
The current study was approved by the Ethics Com-
mittee of Babol University of Medical Sciences
(No.4834).
Measures
Demographic questionnaire
Demographic characteristics including age, educational
level, infertility history, clinical information of PCOS,
and assisted reproductive technology (ART) history were
obtained from the subjects. In addition, weight and height
were measured in order to obtain body mass index (BMI).
Infertility stress
Infertility stress was assessed using FPI developed by
Newton in 1999. It is a multi-dimensional tool to de-
tect stress and infertility problems. The FPI is comprised
of 46 questions divided in five subscales: social con-
cern, sexual concern, relationship concern, rejection of
parenthood, and the need for parenthood. Each item is
scored based on a six-point Likert scale, ranging from 1
(strongly disagree) to 6 (strongly agree). The total score
204 Int J Fertil Steril, Vol 13, No 3, October-December 2019
Basirat et al.

ranges from 46 to 276 with higher scores representing groups. Also, independent samples t test was employed
higher levels of stress (20). Validity and reliability of the to compare the means of age and duration of marriage
Persian version of FPI were previously examined (21). between the two groups. In addition, comparisons of
In the current study, the Cronbach’s alpha coefficient of the mean scores between females with PCOS and those
the FPI was 0.898. without PCOS in all four questionnaires and their sub-
scales including FPI, FSFI, TAS-20, and BDI-II, were
Sexual function done using independent t test. A P<0.0.5 was considered
The FSFI was used to assess sexual function in sub- statistically significant.
jects. The FSFI assesses sexual function over the past four
Results
weeks. It covers six domains: desire, arousal, lubrication,
orgasm, satisfaction, and pain. The score for each domain Table 1 provides the summarized demographic in-
ranges from 0 or 1 to 5 with higher scores representing formation of subjects in the two groups. There were no
better sexual function (22). It was previously shown that significant differences between the two groups regard-
the Persian version of FSFI has high validity and reliabil- ing the subjects’ age, husbands’ age, educational level
ity (23). In the current study, the Cronbach’s alpha coef- of the subjects, educational level of their husbands, and
ficient of the FSFI was 0.896. duration of infertility (P>0.05 in all cases). The fre-
quency of irregular menstruation was significantly high-
Depression symptoms er in females with PCOS than the ones without PCOS
(P<0.001).
Depression was measured by the BDI-II. It is a self-
reported scale and a screening instrument for depression Table 1: Demographic characteristics of women with and without polycystic
with 21 items, most of which assess depressive symptoms ovary syndrome (PCOS)
on a four-point Likert scale ranging from 0 to 3. Total Variable Yes (n=120) No (n=120) P value
scores range from 0 to 63. In clinical settings, the severity
Age (Y) 29.55 ± 5.17 29.33 ± 6.23 0.771
of depression based on BDI-II, is classified as follows:
0-13: minimal depression; 14-19: mild depression; 20- Education 0.278
28: moderate depression; and 29-63: severe depression
≤12 years 51 (56.7) 39 (43.3)
(24). A valid Persian version of the BID-II was used in
the current study. The internal consistency (Cronbach’s >12 years 63 (49.2) 65 (50.8)
alpha=0.87) and test re-test reliability (r=0.74) of the BMI 0.218
BID-II Persian was high and acceptable (25). In the cur-
rent study, the Cronbach’s alpha coefficient of the BDI-II <25 41 (34.2) 29 (24.2)
was 0.915. 25-29.99 45 (37.5) 52 (43.3)
≥30 34 (28.3) 39 (32.5)
Alexithymia
Duration of infertility (Y) 0.159
In the current study, alexithymia was assessed using
TAS-20. It is one of the most common instruments to <5 66 (74.2) 56 (64.4)
measure alexithymia that has 20 items in three sub- ≥5 23 (25.8) 31 (35.64)
scales: difficulty to describe emotions, difficulty to
identify feelings (DIF), and externally-oriented think- Regular menstruation <0.001
ing. Items are scored based on a five-point Likert
scale, ranging from 1 (strongly disagree) to 5 (strongly Regular 64 (53.3) 93 (77.5)
agree). The total alexithymia score ranges from 20 to Irregular 56 (47.7) 27 (22.5)
100 (26). A study conducted by Besharat supported the
Duration of marriage (Y) 5.9 ± 3.99(5) 6.04 ± 3.88(5) 0.587
internal consistency, test-retest reliability, and concur-
rent validity of the Persian version of TAS-20 (27). In Husband’ age (Y) 33.06 ± 5.43 32.66 ± 4.82 0.554
the current study, the Cronbach’s alpha coefficient of Husbands’ education* 0.504
the TAS-20 was 0.809. ≤12 years 54 (47.8) 45 (43.3)
>12 years 59 (52.2) 59 (56.7)
Statistical analysis
Data are presented as mean ± SD or n (%). BMI; Body mass index, *; There were some miss-
All data were analyzed using SPSS for Windows, ing data; therefore, the sum of the frequencies for qualitative variables is not equal to 120.
version 18.0 (SPSS Inc., Chicago, IL, USA). To pre-
sent characteristics of females with and without PCOS, Table 2 a comparison in the mean scores of FPI, FSFI,
continuous variables are expressed as mean ± SD and BDI-II, and TAS-20 between the two groups. The re-
categorical variables as numbers (%). Chi-square test sults of the t-test revealed that females with PCOS had
was employed to compare categorical variables such higher total mean scores of infertility stress (FPI) than the
as educational attainment level, duration of infertility, ones without PCOS (120.68 ± 29.42 vs. 112.83 ± 30.94,
regularity of menstruation, and BMI between the two P=0.046).

Int J Fertil Steril, Vol 13, No 3, October-December 2019 205

 Psychological Profile of Infertile Women with PCOS

Table 2: Comparison of psychological profile of women with and without polycystic ovary syndrome (PCOS)
Variable PCOS P value
Yes (n=120) No (n=120)
Infertility stress (FPI)
Social concerns 24.20 ± 8.31 21.74 ± 8.39 0.024
Sexual concerns 17.53 ± 7.98 16.75 ± 7.81 0.455
Marital concerns 25.15 ± 7.25 24.30 ± 7.34 0.371
Acceptance of life without child 18.57 ± 7.28 16.27 ± 7.87 0.021
Need for parenthood 36.06 ± 9.56 35.15 ± 9.67 0.467
Total scores 120.68 ± 29.42 112.83 ± 30.94 0.046
Alexithymia (TAS-20)
Difficulty in describing feelings 15.17 ± 4.08 13.94 ± 3.62 0.015
Difficulty in identifying feelings 22.62 ± 6.06 19.74 ± 6.03 <0.001
Externally-oriented thinking 22.04 ± 4.26 22.38 ± 4.03 0.532
Total scores 59.83 ± 11.36 55.69 ± 11.52 0.005
Sexual dysfunction (FSFI)
Desire 3.94 ± 0.85 3.92 ± 0.84 0.835
Orgasm 3.5 ± 0.8 3.49 ± 0.84 0.975
Satisfaction 4.78 ± 1.19 4.92 ± 1.05 0.364
Pain 4.64 ± 1.13 4.80 ± 1.16 0.279
Arousal 3.92 ± 0.92 3.88 ± 0.91 0.752
Lubrication 4.41 ± 0.85 4.49 ± 0.73 0.476
Total scores 25.13 ± 3.95 25.35 ± 3.87 0.660
Depression symptoms (BDI-II) 18.06 ± 12.03 15.65±11.76 0.121
Severity of depression 0.114
Minimum 31 (26.1) 46 (39.0)
Mild 35 (29.4) 27 (22.9)
Moderate 33 (27.7) 33 (28.0)
Severe 20 (16.8) 12 (10.1)
Ranges scores; social concern (1-60), sexual concern (1-48), relationship concern (1-60), rejection of life without child (1-48), need for parenthood (1-60), total scores of infertility
stress (46-276). Difficulty in describing emotions (1-25), Difficulty in identifying feeling (1-35), Externally-oriented thinking (1-40), total scores of alexithymia (20-100). Desire (6-0),
arousal (6-0), lubrication (6-0), orgasm (6-0), satisfaction (6-0), pain (6-0), total scores of sexual dysfunction (36-0). Depression symptoms (0-63), Minimum (0-13), mild (14-19), moder-
ate (20-28), severe (29-63). Data are presented as mean ± SD or n (%).

Of the subscales of infertility stress, the mean scores of

social stress and rejection of life without child were high-
er in females with PCOS than those of the other group
(P=0.024 and P=0.021, respectively). There were no sig-
nificant differences in the mean scores of subscales of
sexual stress, marital stress, and parental stress between
the two groups. Also, females with PCOS had higher to-
tal mean scores of alexithymia symptoms (TAS-20) than
the ones without PCOS (59.83 ± 11.36 vs. 55.69 ± 11.52,
P=0.005). Of the subscales of TAS-20, DIF and difficulty
to describe feeling were significantly higher in females
with PCOS than the ones in the other group (P<0.001 and
P=0.015, respectively). There was no significant differ-
ence between the two groups in the mean scores of de-
pression symptoms. In addition, severity of depressive
symptoms did not significantly differ between the two
groups (18.06 ± 12.03 vs. 15.65 ± 11.76, P=0.121). Total
scores of FSFI and all its six subscales did not significant-
ly differ between the two groups (25.13 ± 3.95 vs. 25.35
± 3.87, P=0.660).
Discussion
The current study aimed at comparing the psychologi-
cal profiles of infertile females with PCOS with those of
women without PCOS. The results showed that females
with PCOS had higher total mean scores of infertility
stress (FPI) than the ones without PCOS. Infertile fe-
males with PCOS had more social concerns than the ones
in the other group. Also, infertile females with PCOS had
more stress of rejection of life without child than the other
group. To the authors' best knowledge, no published study
has examined various aspects of infertility stress in infer-
tile females with and without PCOS. However, some stud-
ies evaluated social relationships in patients with PCOS
compared to the controls. Such studies reported that the
social relationships of patients with PCOS was more im-
paired compared to the normal population (28, 29). A re-
cent study on the development of specific measurements
of quality of life in patients with PCOS emphasized on the
negative effects of PCOS on family and friends and social

206 Int J Fertil Steril, Vol 13, No 3, October-December 2019

Basirat et al.
relationships (30). Consistently, another study reported
that the majority of females with PCOS (76.1%) worried
about their future life without any children (15).
Now, higher intensity of infertility stress observed in in-
fertile females with PCOS compared to the ones without
PCOS, should be explained. There are some hypotheses
to explain this finding. First, the secondary analysis of the
data showed that symptoms of PCOS such as obesity and
hirsutism were related to infertility stress. Second, some
previous studies confirmed that females with PCOS expe-
rienced social pressure due to hirsutism, especially exces-
sive facial hair (31). A study showed that hirsutism score
of females with PCOS was significantly correlated with
mental health status (32). Infertile females with PCOS
that had hirsutism felt “unfeminine” and “different” (33).
Therefore, social concerns of infertile females with PCOS
may be more than those of the ones without PCOS.
In contrast with the current study’s expectation, the total
scores of FSFI and all of its six subscales did not signifi-
cantly differ between females with PCOS and those with-
out PCOS. Results of some previous studies were consist-
ent with the findings of the present study reporting that
females with PCOS did not have more depression symp-
toms than the ones without PCOS (34, 35). However, a
study reported that infertile females with PCOS had sig-
nificantly higher depression scores compared to the ones
without PCOS (36). A study reported that females with
PCOS with ones with no desire for a child did not show
significant differences in specific aspects of sexual satis-
faction compared to the ones with no desire for a child
(17). A recent study reported no significant difference in
female sexual dysfunction disorders between infertile fe-
males with PCOS and those without PCOS (16).
The current study also aimed at comparing the alex-
ithymia between infertile females with and those without
PCOS. The results of the current study indicated that in-
fertile females with PCOS had higher alexithymia scores
than the ones without PCOS. Infertile females with PCOS
had more difficulty to identify their feelings and describe
their emotions compared to the ones without PCOS. To
the authors’ best knowledge, no previous study assessed
the alexithymia in infertile females with PCOS. Although
the current study did not have enough information about
the reasons for higher alexithymia in females with PCOS
compared to the ones without PCOS, several hypotheses
could be proposed. First, there are associations between
alexithymia and maladaptation to stress. A study inves-
tigated the association between alexithymia and fertility-
related stress in females with infertility demonstrated that
alexithymia was related to fertility-related stress. The
authors concluded that alexithymia acted as a secondary
coping strategy in females with infertility (37). Second,
alexithymia is related to somatization disorders. A recent
meta-analysis reported that females with PCOS were more
likely to have higher somatization disorders compared to
the ones without PCOS (38). Third, another study intro-
duced alexithymia and somatization as the consequences
Int J Fertil Steril, Vol 13, No 3, October-December 2019 207
of maladaptation to stress of infertility (39). Therefore, it
is supposed that high somatization in females with PCOS
and infertility was comorbid with alexithymia and higher
infertility stress than ones without PCOS.
Due to some limitations of the current study, data
should be interpreted with caution. First, the case-control
nature of the current study prevents drawing any con-
clusions concerning possible relationships. Prospective
cohort studies in the area using reliable approaches are
required to describe the casual relationship between infer-
tile females with PCOS and those without PCOS. Second,
data was collected using self-report scales that may result
in underreporting of the conditions. Future studies using
more reliable methods such as interviewing, might give a
better picture of the psychological profile of infertile fe-
males with PCOS. Third, all of the patients included in
the current study were recruited from one hospital, rather
than multiple centers, that could be a limitation of the cur-
rent study. Fourth, the study sample was small and cannot
be generalized to numerous phenotypes of PCOS. Fur-
ther, multi-centered studies with larger sample sizes are
recommended. Finally, since the study was the first work
that showed higher alexithymia in infertile females with
PCOS, more studies in the area should investigate the ex-
tent of the associations between alexithymia and PCOS
in females with infertility. Additionally, future studies are
required to clarify how alexithymia arises in infertile fe-
males with PCOS.
Conclusion
The current study results showed that infertile females
with PCOS experience more infertility stress than the
ones without PCOS. Also, infertile females with PCOS
had higher means of alexithymia, especially with respect
to the ability to distinguish and describe, compared to the
ones without PCOS. The results of the current study indi-
cated that infertility care providers should provide more
psychosocial support for infertile females with PCOS.
The current study was a step to present the profiles of in-
fertile females with PCOS; thus, further longitudinal stud-
ies are required to follow the changes in psychological
profiles of females with and without PCOS during infer-
tility treatment.
Acknowledgements
The authors thank all of the patients who participated
in the study. We also thank the physicians and staff of the
Infertility Center who referred the patients to the study.
The Deputy Research of Babol University of Medical Sci-
ences approved and financially supported the study. The
authors report no conflict of interest.
Authors' Contributions
Z.B., M.F.; Designed the study. S.A.F., T.M.; Wrote the
protocol and collected the data. M.F., Z.B., S.E.; Wrote
the protocol, and the first draft of the manuscript. Z.G.;

Performed analyses and designed the study. All authors
read and approved the final manuscript.
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